Nocturnal enuresis in children: understanding the causes and providing treatment solutions Nocturnal enuresis in children means involuntary excretion of urine during night sleep, while a child of this age is expected to be able to maintain bladder control. This issue is considered normal in children under four years of age, but if it continues until school age, it needs investigation and treatment. In this article, the causes of nocturia in children and its treatment methods have been investigated.

What is enuresis? Nocturnal enuresis is the involuntary discharge of urine during sleep that occurs after the age when a person is expected to be able to control the bladder. This condition is more common in children and several factors such as delay in bladder growth, excessive production of urine at night, genetic factors, stress and hormonal inconsistencies can play a role in its occurrence. In terms of classification, enuresis is divided into two types: primary (which has existed since the beginning) and secondary (which appears after a period of bladder control). In most cases, this problem is temporary and gradually improves with age. Types of enuresis in children Bedwetting can be examined from different points of view, we examine one of the main categories. ### 1- Initial nocturia This type of nocturnal enuresis can be seen from childhood (from birth) until the end of thirteen or fourteen years of age, which is often affected by physical (physiological) factors. ### 2-Secondary enuresis In this type of urinary incontinence, affected children are normal for a while in terms of controlling urination, and suddenly they suffer from this complication or change in behavior. This condition is more frequent especially after the age of fourteen, and often environmental and psychological factors play a role in its creation. Criteria for nocturnal enuresis in children - The person repeatedly urinates on the mattress or clothes (intentionally or unintentionally) - This behavior is clinically important and one of these two conditions can show this issue: the person shows this behavior at least twice a week and for at least three consecutive months, or experiences clinically significant distress or dysfunction in social, educational (occupational) or other areas of life. - The person's chronological age is at least 5 years old (or at an equivalent developmental level) - This behavior cannot be attributed to the direct physiological effect of a substance (eg, diuretic or antipsychotic drug) or another medical condition (eg, diabetes, spina bifida, or a seizure disorder). (American Psychological Association, Diagnostic and Statistical Manual of Mental Disorders DSM-5-TR, Dr. Mehdi Ganji, Tehran, Savalan) Causes of nocturnal enuresis in children Nocturia in children can occur in some people due to various physical and psychological reasons. Among the common causes of this problem in children, the following can be mentioned: - Small size of the bladder, which may reduce the ability to hold urine. - Urinary tract infections that can lead to frequent urination and incontinence. - Stress, fear or insecurity that has a direct impact on bladder control. - Nervous disorders such as stroke that disrupt bladder function. - Enlargement of the prostate gland that can affect the normal flow of urine. - Sleep apnea (abnormal interruptions in breathing during sleep) that may lead to nocturia. - Constipation that can increase the pressure on the bladder and make it difficult to control urine. - Some problems resulting from mental retardation Another reason for nocturnal urination in children is hormonal imbalance. The body naturally produces a hormone called antidiuretic hormone (ADH) that reduces the amount of urine produced during the night. In people whose body does not produce enough ADH, more urine is produced and the bladder may not be able to hold it during the night. Also, diabetes is another factor that can cause nocturnal urination. In diabetics, the body does not have the ability to process glucose (sugar) properly, and as a result, the amount of urine production may increase. This condition can cause children who are usually dry during the night to have nocturnal enuresis. Knowing these factors helps to better understand the cause of nocturnal enuresis and to choose appropriate methods for its management and treatment. Practical recommendations to prevent bedwetting in children - Limit drinking liquids before the child sleeps. Limiting liquids should be at least two to three hours before the child sleeps. - Send the child to the toilet before sleeping. - Leave the toilet light on at night, sometimes the fear of the dark makes the child not leave his bed. - You can get help from the token economy method. Draw a table for the child and note every day whether he spent the previous night dry or wet. Give him stars for dry nights and praise him after he gets a few stars. - There are also exercises to stimulate and strengthen the bladder muscles that can be useful. Some types of sports are suggested: A. The child sleeps on his back on the floor and his legs are held by the knees by another person and the child puts his hands behind his head and sleeps. It is better to do this ten times and repeat it two or four times. b. The child stands up, puts his hands forward and sits down and gets up ten times. c. The child swims ten times. (Bayan, Zahra, from tension to asimagi, first volume, Tehran, Mirmah) How is nocturia diagnosed in children? To identify the cause of nocturia in children, the doctor usually conducts consultation, examination and necessary tests. First, the child's medical history is reviewed and a physical examination is performed to evaluate the possibility of underlying problems that may have caused urinary incontinence. In some cases, additional tests such as blood and urine tests are performed to check for diseases such as diabetes, urinary tract infections, hormonal imbalances, or kidney problems. **Diagnosis stages of nocturnal enuresis in children** 1. ### Review of medical records and information of parents To better understand the child's condition, the doctor asks questions about the following: - Family history of nocturia - Fluid consumption during the day and night Pain or burning sensation when urinating - Experiencing recent stress Digestive problems such as constipation Color and clarity of urine (dark, cloudy or with blood) 2. ### Physical examination By performing a detailed examination, the doctor checks the possibility of structural or functional problems of the urinary system. This examination may include examining the abdomen, back, and genitals for signs of physical abnormalities or symptoms related to underlying diseases. 3. ### Additional tests To make sure nocturia is not caused by a more serious condition, your doctor may order the following tests: - Urine test: to check urinary infections, the presence of excess sugar (diabetes) or other abnormalities. - Blood test: to evaluate blood sugar level, kidney function and check hormonal imbalance. Blood pressure measurement: to identify possible problems related to the kidney or circulatory system. Finally, a combination of these tests will help the doctor to identify the cause of the child's nocturnal urination and suggest the best treatment method. When do we need to see a doctor? If the child's bedwetting continues continuously and repeats for more than a few nights, we must first identify the root cause of the problem. If we cannot find its source, it is better to consult a doctor. Usually, the best time to treat bedwetting in children is between 5 and 7 years old. Of course, treatment methods may be different depending on the age of the child. For example, the treatment of enuresis for 6-year-old children may be different from the treatment of enuresis for 8-year-olds. Also, if the child complains of burning when urinating, or abnormally frequent urination during the day or night, or itching of the anus or penis, you should see a doctor immediately. First, the doctor will look for the root cause of the problem by taking the child's medical history. Urine and stool tests are performed to identify the possibility of infection in the urinary tract or kidney, and if necessary, imaging of the bladder and kidney is performed. Usually, this treatment process is used in secondary enuresis. After the necessary examinations, the doctor will suggest the appropriate treatment method. In some cases, nocturnal enuresis is not caused by physical problems, for example, a child may suffer from nocturnal enuresis as a result of stress and anxiety, in which case you should seek help from psychologists and psychiatrists who specialize in this field. Finally, bedwetting is a common phenomenon among children. Although it may not cause much concern at first glance, it is necessary to follow it up and ensure proper treatment. You can get the necessary information through an online or face-to-face consultation with a child psychologist at Pirouz Psychology Center.

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